Computerized Dynamic Posturography

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For related information, refer to the Transtympanic Micropressure policy

Policy and Rationale:

Due to insufficient clinical evidence to support medical efficacy, computerized dynamic posturography (CDP) testing, also called balance board testing or equilibrium platform testing (EPT), for evaluating balance disorders will not be reimbursed by Oxford®. This service is not proven to be clinically effective and, therefore, is not considered to be medically necessary.

The overall quality of the evidence on the efficacy of computerized dynamic posturography (CDP) for evaluation of vestibular disorders is weak. There is a lack of well-designed, prospective, randomized controlled trials using blind assessment to demonstrate the diagnostic utility of CDP compared with standard tests. There are no reliable data demonstrating any consistent, beneficial effect of CDP testing on patient outcomes.

Description of Service/Assessment/Background Information:

Computerized dynamic posturography (CDP), also known as moving platform posturography or dynamic posturography, uses a platform device for evaluating a patient's ability to maintain balance (Hayes, 2008). CDP has been used to measure a patient's ability to maintain balance under varying conditions when the usual cues that one relies upon to remain upright, vision, proprioception, and vestibular function, are manipulated. The goal of testing is to isolate vestibular symptoms to a specific cause that can often be treated.

Standard diagnostic tests include electronystagmography and rotational chair tests, which evaluate eye movements in response to a number of different stimuli including the position and rotation of the head.

Clinical Evidence:

No new studies have been identified since 2008.

In a systematic review, Piirtola and Era (2006) evaluated prospective studies where force platform measurements were used as predictors of falls among elderly populations. Nine original prospective studies were included in the final analyses. In five studies fall-related outcomes were associated with some force platform measures and in the remaining four studies associations were not found. Measures related to dynamic posturography (moving platforms) were not predictive of falls. The results suggest that certain aspects of force platform data may have predictive value for subsequent falls, especially various indicators of the lateral control of posture. However, the small number of studies available makes it difficult to draw definitive conclusions.

A validation study by Sataloff et al. (2005) found that CDP was less specific than electronystagmography (ENG), but it provided more global insight into a patient's ability to maintain equilibrium under more challenging environmental circumstances. CDP showed value in obtaining objective confirmation of an abnormality in some dizzy patients whose ENG findings are normal.

Patients with vestibular loss (11 with bilateral and 101 with unilateral vestibular loss) were investigated with posturography and compared to healthy subjects. The results showed that in static conditions, only bilateral vestibular loss patients had abnormal values compared to controls. In contrast, in dynamic eyes-closed conditions, both bilateral and unilateral patients could be differentiated from controls. Bilateral patients were unable to stand up without falling in both pitch and roll planes. Unilateral patients fell in the first week post-lesion and showed increased postural oscillations from the 2-week up to the 1-year post-lesion stage. The authors concluded that dynamic posturography could be a valuable tool for diagnosis and analysis of imbalance in patients with unilateral vestibular loss. While the investigators found value in CDP, this study lacked randomization and utilized unbalanced study groups. (Mbongo, 2005)

A study of 75 patients investigated the use of CDP for clinical staging of vestibular diseases such as Meniere's disease. A statistically significant relationship between audiometric hearing threshold and CDP scores was found, especially in patients with advanced audiometric disease. CDP scores showed statistically significant variation with time elapsed since the last vertigo attack, allowing staging in terms of balance and posture. Non-randomization, lack of a control group and small sample size limit the usefulness of these results. (Soto, 2004)

Artuso et al. (2004) conducted a validation study using 23 normal subjects and 16 patients with vestibular impairment. Normal subjects were studied during a state of simulated vertigo. Using EquiTest in combination with conventional methods, it was possible to differentiate malingerers from non-malingerers with 86.9% sensitivity and 89.7% specificity. Small sample size and poor study design limit the usefulness of these results.

A Hayes report evaluated available evidence on CDP for diagnosing vestibular disorders. The review included one meta-analysis and 10 additional studies, many of which were non-comparative. The meta-analysis (n=1477) conducted by Di Fabio (1996), reported a sensitivity and specificity of approximately 50% for CDP used to diagnose vestibular disorders. The Hayes review determined that the overall quality of the evidence on the efficacy of CDP for the evaluation of vestibular conditions is weak. There were no well-designed prospective, randomized clinical trials demonstrating the diagnostic utility of CDP compared with standard tests (Hayes, 2008).

Professional Societies:American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS)
AAO-HNS recognizes that the following tests or treatments are medically indicated and appropriate in the evaluation or treatment of persons with suspected balance or dizziness disorders:

rotational chair step velocity testing

harmonic acceleration testing

vestibular rehabilitation therapy including the use of therapy devices

dynamic platform posturography

This statement is not part of a formal guideline and is not supported by clinical evidence. (AAO-HNS, 2007)

Devices for testing vestibular dysfunction are captured in the FDA 510(k) database under Product Code LXV (Vestibular Analysis Apparatus) and/or Product Code KHX (Force-Measuring Platforms). Devices with Product Code LXV are unclassified and devices falling under the Product Code KHX are 510(k)-exempt. See the following Web site for more information: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPCD/classification.cfm. Accessed January 10, 2011.

Another device mentioned in the literature is the Balance Quest™ (also known as System 2000; Vorteq) (Micromedical Technologies Inc.), which is listed as an unclassified device. See the following Web sites for more information:

Coding Clarification
Computerized dynamic posturography is not medically necessary for all diagnosis codes.

The foregoing Oxford policy has been adapted from an existing UnitedHealthcare national policy that was researched, developed and approved by the UnitedHealthcare Medical Technology Assessment Committee. [2011T0208H]

Mbongo F, Patko T, Vidal PP, et al. Postural Control in Patients with Unilateral Vestibular Lesions Is More Impaired in the Roll than in the Pitch Plane: A Static and Dynamic Posturography Study. Audiol Neurootol. 2005 May 30;10(5):291-302.